Developing minimum clinical standards for physiotherapy in South African ICUs: A qualitative study

Rationale, aims, and objectives: Physiotherapists are integral members of the intensive care unit (ICU) team. Clinicians working in ICU are dependent on their own experience when making decisions regarding individual patient management thus resulting in variation in clinical practice. No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for ICU physiotherapy. This study explored perceptions of physiotherapists on minimum clinical standards that ICU physiotherapists should adhere to for delivering safe, effective physiotherapy services to critically ill patients. Method: Experienced physiotherapists offering a service to South African ICUs were purposively sampled. Three focus group sessions were held in different parts of the country to ensure national participation. Each was audio recorded. The stimulus question posed was “What is the minimum standard of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs?” Three categories were explored, namely, knowledge, skill, and attributes. Themes and subthemes were developed using the codes identified. An inductive approach to data analysis was used to perform conventional content analysis. Results: Twenty-five physiotherapists participated in 1 of 3 focus group sessions. Mean years of ICU experience was 10.8 years (±7.0; range, 3-33). Three themes emerged from the data namely, integrated medical knowledge, multidisciplinary teamwork, and physiotherapy practice. Integrated medical knowledge related to anatomy and physiology, conditions that patients present with in ICU, the ICU environment, pathology and pathophysiology, and pharmacology. Multidisciplinary teamwork encompassed elements related to communication, continuous professional development, cultural sensitivity, documentation, ethics, professionalism, safety in ICU, and technology. Components related to physiotherapy practice included clinical reasoning, handling skills, interventions, and patient care. Conclusions: The information obtained will be used to inform the development of a list of standards to be presented to the wider national physiotherapy and ICU communities for further consensus-building activities

Editorial

Mapping of a curriculum renewal journey: Lessons learne

The detection of occult metastatic disease in patients with cutaneous melanoma

The ability to identify melanoma patients with progressive disease is central to efficient management. The challenge therefore, is to develop prognostic markers and techniques which will allow the identification of those patients whom, at the time of primary tumor diagnosis, already have micrometastases (occult or clinically undetectable metastases). The use of the reverse transcription-PCR (RT-PCR) technique for the detection of circulating melanoma cells (CMCs) is potentially a powerful tool for identifying those patients at risk for developing metastases. The first aim of this study was to develop a more sensitive, reproducible, cost effective and clinically applicable assay and to eliminate the problem of false positives. A combined RT-PCR assay for tyrosinase mRNA, a marker specific for melanoma cells, was developed and tested. It was shown that the assay can reproducibly detect a single, viable melanoma cell in 10-15 ml of peripheral blood. Furthermore, a simple but effective procedure was developed to prevent carryover contamination. It was found that the chance of obtaining normal melanocyte contamination with the needle prick during blood sampling was only 2% and that illegitimate transcription does not contribute to sporadic false positives. The second aim of this study was to determine whether the early detection of CMCs is of any clinical value to monitor melanoma progression. Peripheral blood samples from 143 patients with primary melanoma (PM) were analysed by RT-PCR for the presence of tyrosinase mRNA. Seven percent (10/143) of the patients with PM had detectable CMCs. The percentage of PCR-positive patients was higher for stage II patients (9.0%) compared to stage I (5.3%) but the difference was not significant. A significantly higher percentage (P < 0.05) PCR-positive patients were found to have tumors greater than 1.5 mm thick and with ulceration present. Although this finding supports the notion that tumor thickness and ulceration are the two most significant prognostic factors, it was not possible at this stage, to link this directly to a poor prognosis since the majority of the PCR-positive patients have not yet (within four years) developed metastatic disease. However, the data does indicate that cells from tumors greater than 1.5 mm thick and with ulceration have a greater propensity to enter the circulation but that these cells do not necessarily have the ability to establish metastases. The results suggest that the detection rate of 9% for patients with stage II disease is much lower than would be expected, since 23.9% (16/67) of the stage II patients subsequently developed metastases. Of these 16 patients, only one was PCR-positive, one week before the metastases became clinically evident. Thus, the current technique fails to predict the likelihood of developing metastatic disease (P = 0.3485). The other nine PCR-positive patients had not yet developed metastases after a median follow-up period of four years. It is concluded that the current technique for the detection of CMCs is of limited clinical value to predict the likelihood of metastasis in patients with PM. It is suggested that other anatomic compartments, such as sentinel lymph nodes, should be explored for the identification of patients at risk for developing metastases. The third aim of this study was to determine whether high or low plasma levels and/or activity of plasminogen activator inhibitor type 1 (PAI1) correlate with the presence of metastatic disease in patients with melanoma. PAI1 is considered to be the main regulator of fibrinolytic activity in blood and has been identified as a key enzyme in the metastasis and vascularization of solid tumors. A unique enzyme-linked immunosorbant assay was developed to measure both the total amount of PAI1 in plasma as well as the active fraction of the inhibitor. This novel assay was then used to analyse and compare the plasmatic PAI1 levels and activity of a group of patients with advanced melanoma (AM) with a group of patients with primary disease and a control population. There was no statistical difference in the total plasmatic PAI1 levels between the controls and patients with PM and AM (P = 0.6199). In contrast, there was a significant difference in the active fraction of PAI1 between the controls and patients with PM or AM (P = 0.0076). A value of less than 44% active PAI1 was shown to be clinically meaningful by linear discriminant analysis. This means that a melanoma patient with a plasmatic PAI1 activity value less than 44% will have a 50% chance of harbouring metastases. Of the patients with PM, 19% had PAI1 activity values less than 44%, which strongly supports further investigations to determine whether plasmatic PAI1 activity levels might be predictive of metastatic disease. The false positive rate was 2.6%. It is speculated that this reduction in the active fraction of PAI1 for patients with AM might be attributed to tumor-derived tissue plasminogen activator and/or other melanoma-derived proteases or factors. The last section of this study describes several monoclonal antibodies (Mabs) that were developed against PAI1 in order to obtain useful reagents to study the regulatory functions of PAI1 in the metastasis and vascularization of solid tumors. The baculovirus expression system was used to express human PAI1 in insect cells and the crude infected cell population was used as the immunogen in mice. This approach was followed since the Escherichia coli-derived recombinant molecule elicited a poor immune response. A unique panel of anti-PAI1 Mabs was developed that were characterized with regard to their use for immunoblotting, immunofluorescence and immunocytochemistry. One of these antibodies blocked the binding of PAI1 to vitronectin and inhibited the activity of the inhibitor. Finally, two of these Mabs turned out to be extremely valuable and were used to develop a novel microtiter plate assay for measuring the active fraction of PAI1 in biological fluids by making use of Mabs against different epitopes of PAI1

The 14C content of the ethanol of South African wines ior the years 1925-1975

It has been shown that, due to atmospheric conditions, South African natural wines are lower in 14C content than their northern hemisphere counterparts for the periods of active nuclear explosion tests. On this basis it is incorrect to apply northern hemisphere 14C data to wines of the southern hemisphere.Der 14C-Gehalt des Äthanols südafrikanischer Weine der Jahrgänge 1925-1975Es konnte gezeigt werden, daß südafrikanische Naturweine infolge der atmosphärischen Bedingungen einen niedrigeren 14C-Gehalt besitzen, als ihn Vergleichsweine von der nördlichen Erdhalbkugel aus der Zeit der Kernwaffenversuche aufweisen. Es ist somit nicht gerechtfertigt, die 14C-Werte der Nordhemisphäre bei Weinen der südlichen Erdhalbkugel anzuwenden

Reliability of ultrasonic diaphragm thickness measurement in mechanically ventilated infants and children: A pilot study

Background. Diaphragmatic atrophy in mechanically ventilated infants and children may be due to ventilator-induced diaphragmatic dysfunction, which could lead to extubation failure. Ultrasound may be used as a means by which diaphragmatic atrophy can be reliably identified. There are currently no data reporting on the use of ultrasound to monitor diaphragm atrophy in the paediatric population. Objectives. To assess the inter- and intra-rater reliability of using ultrasound to measure diaphragm thickness in mechanically ventilated infants and children. Method. Diaphragm thickness measurements were compared between two individual researchers for inter-rater reliability and between multiple measurements from a single researcher for intra-rater reliability. Measurements were compared using Intraclass correlation coefficients and Bland- Altman plots. Results. Results indicated excellent reliability between measurements for both inter-and intra-rater reliability, with slightly better reliability for intra-rater compared with inter-rater reliability. Intraclass correlation coefficients for inter-rater reliability were between 0.77 and 0.98, and 0.94 for intra-rater reliability. Conclusion. Ultrasound measurements of diaphragm thickness can be used to reliably measure diaphragm thickness in mechanically ventilated infants and children. This modality could therefore be used as a reliable outcome measure for future clinical research studies to establish the relationship between ventilator-induced diaphragmatic atrophy and children who are at risk for extubation failure

Exploring linkages between drought and HIV treatment adherence in Africa: A Systematic Review

Climate change is directly and indirectly linked to human health, including through access to treatment and care. Our systematic review presents a ‘systems’ understanding of the nexus between drought and antiretroviral treatment (ART) adherence in HIV-positive individuals in the African setting. Narrative synthesis of 111 studies retrieved from Web of Science, PubMed/Medline, and PsycINFO suggests that economic and livelihoods conditions, comorbidities and ART regimens, human mobility, and psycho-behavioural dispositions and support systems interact in complex ways in the drought-ART adherence nexus in Africa. Economic and livelihood-related challenges appear to impose the strongest impact on human interactions, actions and systems that culminate in non-adherence. Indeed, the complex pathways identified by our systems approach emphasise the need for more integrated research approaches to understanding this phenomenon and develop interventions

Economic, social and demographic impacts of drought on treatment adherence among people living with HIV in rural South Africa: A qualitative analysis

The 2015 El Niño-triggered drought in Southern Africa caused widespread economic and livelihood disruption in South Africa, imposing multiple physical and health challenges for rural populations including people living with HIV (PLHIV). We examined the economic, social and demographic impacts of drought drawing on 27 in-depth interviews in two cohorts of PLHIV in Hlabisa, uMkhanyakude district, KwaZulu-Natal. Thematic analysis revealed how drought-enforced soil water depletion, dried-up rivers, and dams culminated in a continuum of events such as loss of livestock, reduced agricultural production, and insufficient access to water and food which was understood to indirectly have a negative impact on HIV treatment adherence. This was mediated through disruptions in incomes, livelihoods and food systems, increased risk to general health, forced mobility and exacerbation of contextual vulnerabilities linked to poverty and unemployment. The systems approach, drawn from interview themes, hypothesises the complex pathways of plausible networks of impacts from drought through varying socioeconomic factors, exacerbating longstanding contextual precarity, and ultimately challenging HIV care utilisation. Understanding the multidimensional relationships between climate change, especially drought, and poor HIV care outcomes through the prism of contextual vulnerabilities is vital for shaping policy interventions

Exploring linkages between drought and HIV treatment adherence in Africa: a systematic review

Climate change is directly and indirectly linked to human health, including through access to treatment and care. Our systematic review presents a systems understanding of the nexus between drought and antiretroviral therapy (ART) adherence in HIV-positive individuals in the African setting. Narrative synthesis of 111 studies retrieved from Web of Science, PubMed/MEDLINE, and PsycINFO suggests that livelihoods and economic conditions, comorbidities and ART regimens, human mobility, and psychobehavioural dispositions and support systems interact in complex ways in the drought–ART adherence nexus in Africa. Economic and livelihood-related challenges appear to impose the strongest impact on human interactions, actions, and systems that culminate in non-adherence. Indeed, the complex pathways identified by our systems approach emphasise the need for more integrated research approaches to understanding this phenomenon and developing interventions

Metabolite changes in blood predict the onset of tuberculosis

Immunogenetics and cellular immunology of bacterial infectious disease